Search This Blog

When the Diagnosis is : All of the Above

Most of us aren't Diagnostic and Statistical Manual (DSM) experts, but are aware of this thing we call the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders that therapists memorize. The bullet-point system of features at the corner of the desk is likely a well ear-marked spiral-bound copy of the bible. Docs flip easily to a suspected disorder.

Some of us read the patient right away. He belongs to either the anxiety disorder family, or the affective (depressive-manic) disorder tree, because so many of us do. The lucky belong to both. The experienced professional also recognizes substance abuse, eating and gambling disorders, personality disorders, everything.

Still, we work at that differential diagnosis, want to narrow the problem down, if there even is a real disorder, one that has met the full DSM criterion. Not everyone has a particular disorder, but we live in a world replete with mental and behavioral messiness, so a typical therapy visit also means someone else, someone who is not in the room, is the subject of that "See? That's her." Yes, you should worry when your partner gets a therapist.

All well and good. But what's a therapist to do when the patient begins by saying, for example, that as a kid he had an addiction to pot, and can't remember being depressed as it presents in the books, but knows he had suicidal thoughts. He will continue to say that he treated teachers as inferior beings and passive-aggressively refused to answer questions, yet never scored lower than an 90 on a test without studying. She'll tell you, too, change the gender, that she binged and purged before even knowing it would be popular in college, and that by the age of twenty started having obsessive thoughts when she saw a knife, visualizing the knife slashing her of its own accord. Or she might irrepressibly slash herself. Add to this a social network disorder that culminated in job loss, and compulsive sexual relationships on the internet. Oh, and she has a new job and she hates it.

All this without any family history, as if to say, It is my genetics that made me do it. I have a mental disorder and none of the doctors in the past have managed to narrow it down. Would you do that for me please? I'm under a lot of stress.

I look at you, do my best to read you. You return the favor, read me. I ask, How did you find me? Why me? This yields wonderful diagnostic information. Another question: What does your primary care doctor think?

Inevitably, assuming the pri-care is a family physician, the answer is: That I need counseling. I need to talk to someone like you.

Those of us who have helped people in one or two visits, who specialize in "only evaluations" or are in a hurry or don't have evening appointments might want to pass him on to another therapist. Our patient with a million symptoms and as many diagnoses and problems likely had a very messy childhood. One of my mentors once told me that if a person has been incested, that means twice a week for years.

Makes sense, right? There are so many forms of incest, is the thing, and indeed, twice a week on the couch for years is an incredible luxury. And it usually isn't necessary, all due respect. Who has that kind of time? Job stress is at the top of the list. There is a V-code, I think, for that.

Upshot: If the patient with All of the Above* is your new patient, then settle back and relax. Feet up on the ottoman. Do the therapy that the primary care doctor has asked you to do. And don't worry about the diagnosis, the medication, or even who else you think should be in therapy. This one's yours. Embrace it.

therapydoc

All of the Above*: Not to say that there aren't a few diagnoses, but usually there are a few features of several diagnoses. One does have to go through that process, vetting those features, finding illness. All I'm saying is, don't let the diagnostic process get in the way of the therapy. Because it really can, seductive monster that it is.

Comments

clairesmum said…

Good example of what a real person is, not just a written case study. Too bad insurance companies don't understand this! As someone who fits the group identified by your colleague, i can say that long term therapy (1-2x/wk x 28 years and still going) has helped me reconstruct a healthy person from the wreckage and support me in living a full life. Also, good psych meds for the same period of time, good insurance coverage, and a personality that includes curiosity, courage, and perseverance.

Popular Posts

It's a very simple concept, really. But I remember first hearing about it many years ago in graduate school and getting it, but not getting it, and what made it worse was that the instructor, Joy Johnson (where are you, Joy?) made a serious pitch, told us that if we didn't get it, basically, we would be only be so-so at this job. Whereas if we did get it, we had half a chance.

A patient ended up clarifying it for me, unintentionally, of course. Joy taught us that process is what's happening, the action, and that content is the story. There's a difference between seeing something, and hearing about it. The guy selling you a car is going to be friendly, and he'll tell you all about the features and wonders of the vehicle, but if he sells it to you, it is likely because of the way he worked you, not because it's such an awesome car.

I wrote this one to show you how badly I can blow a case, and to make suggestions to increase the odds it won't happen to you.

You people know me as therapydoc, but I do research and have a faculty appointment, too. One day I took a call, expecting it to be a client, but it was the dean asking me if I would please take on a funded project. There is this small problem, she tells me, of acquaintance rape.

Ultimately a new agency to treat college rape survivors off campus gets off the ground because of the project, and I get a paper out of it, present it to the annual meeting for the Council on Social Work Education. It's about how social workers should be treating rape.

But the following story happened years before, when all I had to go on was my fairly extensive knowledge of cognitive behavioral and exposure therapies for anxiety and post traumatic stress. I had used these tools for all kinds of abuse and assault, even for rapes that had happened in the past.

Maybe, instead of lovers, you start out as best friends. Or maybe there has always been chemistry. Maybe someone fixed the two up, thought you would work well together, and you did.

In each case things start out swimmingly, perfectly, and for awhile, maybe even a long while, it's magic, and there's attention and love, and that face I see on the leather sofa two feet away from me is pretty happy.

And the cynic in me waits for the other shoe to drop. Far be it from me to burst anyone's bubble. I'm not your mother. Let the fantasy last. We all need a little hope, and when someone is kind, when someone is attentive, when someone is flirtatious, well, it feels pretty good.

This is the new relationship paradigm, you know, love without commitment. With a divorce rate holding steady at one out of two, what is the point of the crystal and china? Why register at all? Surely weddings are expensive, and happiness a toss of the dice. I'd prefer to think, actually, that…